Rostami et al. BMC Psychiatry (2019) 19:234 https://doi.org/10.1186/s12888-019-2220-6

RESEARCHARTICLE Open Access The relationship between adherence to a Dietary Approach to Stop Hypertension (DASH) dietary pattern and insomnia Hosein Rostami1, Sayyed Saeid Khayyatzadeh1, Hamidreza Tavakoli1, Mohammad Bagherniya2, Seyed Jamal Mirmousavi3, Seyed Kazem Farahmand4, Maryam Tayefi5, Gordon A. Ferns6 and Majid Ghayour-Mobarhan7,8*

Abstract Background: Adherence to a DASH- style diet has been reported to be associated with several health-related outcomes. A limited number of reports suggest that diet is an important behavioral determinant of insomnia. The current study aimed to explore the relationship between adherence to a DASH diet and the prevalence of insomnia in adolescent girls. Methods: A total of 488 adolescent girls aged 12–18 years old were recruited from different regions of Khorasan Razavi in northeastern of Iran, using a random cluster sampling method. DASH scores were determined according to the method of Fung et al. A validated Iranian version of the Insomnia Severity Index questionnaire was used to assess sleep insomnia. To assess the association between the DASH dietary pattern and insomnia, we applied logistic regression analysis in crude and adjusted models. Results: As may be expected, participants in the upper quintile of the DASH diet had significantly higher intakes of fruits, vegetables, low fat dairy products, fish and nuts and lower consumption of refined grains, red and processed meat, sugar-sweetened beverages and sweets. We found that a high adherence to a DASH-style diet was associated with a lower odds of insomnia (OR: 0.51; 95% CI 0.26–1.00) compared with those with lowest adherence. Similar results were found after adjustment for potential confounders. Conclusions: There is an inverse association between adherence to DASH dietary patterns and insomnia. Further prospective studies are required to demonstrate these findings. Keywords: DASH, Diet, Sleep, Insomnia, Adolescent

Background disorders and cardiovascular disease is associated with Insomnia is one of the most common sleep-related ab- chronic insomnia [3]. In addition, people with chronic in- normalities, and is characterized by a difficulty initiating, somnia are more prone to develop severe depression and or maintaining sleep, early morning awakening and non- suicide [4]. Besides the demographic, psychological and restorative sleep [1]. Adolescents are susceptible to sleep behavioral factors, there have been some reports suggest- problems and sleep insuffiency due to the puberty-related ing that diet is an important behavioral factor that may biopsychosocial and physiological changes along with contribute to insomnia [5]. It has been proposed that increased academic demands [2]. An increased risk of higher dietary intakes of total energy, total and trans fat, several deleterious health outcomes including metabolic sodium [5, 6] and caffeine [7]andlowerconsumptionof vegetables [5] might be associated with symptoms of * Correspondence: [email protected] insomnia. However, there are few epidemiological studies 7Metabolic syndrome Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad 99199-91766, Iran that have assessed the association between dietary patterns 8Department of Modern Sciences and Technologies, Faculty of Medicine, and insomnia. Gianfredi et al. have shown that diet may Mashhad University of Medical Sciences, Mashhad, Iran have a substantial impact on several sleep disturbances, Full list of author information is available at the end of the article

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including insomnia [8]. Dietary patterns can be extracted was computed through weight in kilograms divided by using posteriori or priori methods [9–11]. The Dietary height in meters squared. Approach to Stop Hypertension (DASH)- style diet which is characterized by a high consumption of whole grains, Dietary assessment vegetables, fruits, low-fat dairy, nuts and legumes, and re- Dietary data were assessed using a validated and reliable stricted amounts of red or processed meat, sweets, and food frequency questionnaire (FFQ) [16] and completed sugar-sweetened beverages, can be identified as a priori during a face-to-face interview. All reported consump- dietary pattern [12]. There is growing evidence that a tion frequencies were converted to g/d using household greater adherence to a DASH- style diet is associated with measures. Daily intakes of energy and nutrients were lower risks of psychological and physiological disorders computed for each person by using the modified US [13, 14]. Therefore, we hypothesized that adherence to a Department of Agriculture food consumption database. DASH-style diet might have beneficial effects on a healthy sleep pattern. To the best of our knowledge, no previous Adherence to Dash-style diet study has investigated the relationship between a DASH- DASH dietary pattern scoring was defined using the style diet and the prevalence of insomnia. With regard to method of Fung et al. [17]. The score was calculated by the potential importance of DASH-style diet in health considering 8 principle components including dietary in- outcomes and highly prevalence of insomnia, this cross- takes of fruits, vegetables, nuts and legumes, low fat sectional study was carried out to assess the relationship dairy products, whole grains, sodium, sweetened bever- between adherence to a DASH-style diet and the presence ages, red and processed meats. For each of the compo- of insomnia in 488 adolescent girls. nents, study participants were categorized into quintiles 1 to 5 based to their intake ranking (Fruits, vegetables, Methods nuts and legumes, low-fat dairy products, and whole Study design and participants grains); for example, 1 point for quintile 1 and 5 points This cross-sectional study was performed in Khorasan for quintile 5. For sweetened beverages, salt, red and Razavi, in northeastern Iran, in January 2015. A total of processed meats, the highest quintile was given the score 488 student girls aged 12–18 years were randomly se- of 1 and the lowest quintile was given a score of 5. lected by using cluster sampling method among several Finally, the DASH score for each person was calculated schools. We included participants without a history of by summing up the scores of the 8 components and any chronic diseases including metabolic bone disease, ranged from 8 to 40 points. hepatic or renal failure, autoimmune disease, malabsorp- tion or thyroid, cancer, cardiovascular disorders, Assessment of insomnia parathyroid, adrenal diseases and anorexia nervosa or We used a validated Iranian version of the Insomnia bulimia. Subjects with intakes of anti-diabetic, anti-in- Severity Index (ISI) questionnaire to aseess sleep insom- flammatory, anti-depressant or anti-obesity drugs, nia [18]. The ISI questionnaire has seven questions. This vitamin D or calcium supplements and hormone therapy questionnaire has score range between 0 and 4 which is within the previous 6months were also excluded. All stratified into four categories as follows: 0 (None), 1 of the subjects and their parents were asked to pro- (Mild), 2 (Moderate), 3 (Severe) and 4 (Very Severe). vide written informed consent before the beginning of Total score of ISI ranges between 0 to 28 points. If the the study. The study was ethically approved by the ISI score was > 7, an individual was considered to have Medical Ethics Committee of the Mashhad University Insomnia. of Medical Sciences, Mashhad, Iran. (Ethics code number: 931188). Statistical methods Participants were classified into five categories by quin- Demographic and anthropometric assessments tiles of their DASH-style dietary scores. To compare A standard questionnaire was used to obtain general general characteristics of study participants across quin- demographic information including age, smoking status, tiles of DASH score, we applied one-way ANOVA test initiation of menstruation (yes/no), parental death (yes/ for continuous variables (age, physical activity, weight, no) and parental divorce (yes/no) by face-to-face inter- BMI, WHR) and chi-square test for categorical variables view. A validated Modifiable Activity questionnaire was (BMI percentile, passive smoking, menstruation, parent used to determine physical activity levels [15] and death and parent divorce). Linear regression analyses provided as metabolic equivalents in hours per week. An were performed to compare the energy-adjusted dietary experienced technician measured body weight, height, intakes of the study participants across quintiles of waist circumference (WC) and waist to hip ratio (WHR) DASH-style diet. To find the relationship between DASH applying standard protocols. Body Mass Index (BMI) dietary pattern and insomnia, we used multivariate logistic Rostami et al. BMC Psychiatry (2019) 19:234 Page 3 of 7

regression in several models. A crude model was used at insomnia reduced with increasing adherence to a Dash- the first step and then controlled for age and menstru- style diet (OR 0.51; 95% CI 0.26–1.00). Similar results ation. Additional adjustments were conducted for physical were found after full adjustment for confounding factors activity and passive smoking. Finally, further adjustment (OR 0.57; 95% CI 0.27–1.09). was applied for BMI percentile in the third model. A P-value < 0.05 was defined as statistically significant. Discussion All statistical analyses were done using SPSS (SPSS Findings from our cross-sectional study suggest that a Inc., version 17). greater adherence to a DASH-style diet is related to lower prevalence of insomnia in adolescent girls. Similar Results results were found after controlling for confounding Overall, of the 488 subjects who completed the FFQ, variables. Insomnia is one of the most common sleep 118 (24.2%) had some degree of insomnia. Demographic problems that disturb individual’s performance and characteristics of the study population across quintiles of production through reduction in physical and mental DASH score are presented in Table 1. Individuals with abilities. Data from previous epidemiological studies higher adherence to DASH-style diet were slightly youn- demonstrated that individuals suffering from sleep-re- ger. No other significant differences in demographic lated disorders might be at increased risk of obesity, characteristics were observed across quintiles of DASH hypertension, coronary artery disease, metabolic syn- score. Dietary intakes of study participants across cat- drome, diabetes, psychological related disorders and all- egories of DASH-style diet are indicated in Table 2.As cause mortality [19]. expected, subjects with higher DASH score consumed One potential approach to prevent or improve sleep more amounts of fruits, vegetables, nuts, legume, seed, problems and their risk factors is dietary modification. A low fat dairy and whole grain. In addition, lower score of DASH- style diet is considered to be a healthy dietary DASH dietary pattern was associated with higher intakes pattern that has an important protective role in preven- of sweetened beverages, sodium, red and processed tion of chronic diseases including obesity, diabetes, meat. Individuals with the greatest adherence to DASH metabolic syndrome, cardiovascular diseases [11]. More- dietary pattern had higher intakes of total energy, pro- over, a growing body of evidence has shown that a tein, carbohydrate, fiber, vitamin C, vitamin D, folate, greater adherence to DASH dietary pattern is associated potassium, calcium and magnesium and lower intake of to healthier psychological profile [20]. total fat. Multivariable-adjusted odds ratio for insomnia Cheng et al., evaluated the association between diet across quintiles of DASH dietary pattern is shown in quality and probable insomnia in US men population Table 3. Using an unadjusted model, the odds of and reported higher intakes of trans fat and sodium and

Table 1 Descriptive characteristics of study participants by quintiles of DASH-style diet Quintiles of DASH score (ranged from 0 to 40) Q1 (n = 98) Q2 (n = 97) Q3 (n = 97) Q4 (n = 98) Q5 (n = 98) P-valuea Age (y) 15.07 ± 1.4 14.6 ± 1.5 14.6 ± 1.6 14.4 ± 1.5 14.1 ± 1.6 0.002 Physical activity (MET. h/week) 45.1 ± 3.3 45.7 ± 3.2 44.7 ± 2.2 45.3 ± 4.1 45.5 ± 3.6 0.24 Weight (Kg) 52.1 ± 9.09 52.9 ± 11.4 51.4 ± 10.1 54.1 ± 11.4 54.7 ± 12.5 0.27 Waist circumference (cm) 70.2 ± 7.5 70.2 ± 9.1 70.01 ± 8.1 72.2 ± 9.5 71.8 ± 8.9 0.3 BMI (kg/m2) 21.05 ± 3.1 21.2 ± 4.08 20.8 ± 3.4 21.9 ± 4.1 21.8 ± 4.3 0.22 Waist hip ratio 0.76 ± 0.04 0.76 ± 0.05 0.77 ± 0.06 0.77 ± 0.09 0.76 ± 0.05 0.53 BMI percentiles (%) < 5 3.6 3.4 0 1.2 1.1 0.14 5–85 86.5 75.6 85.3 76.1 72.5 85–95 8.1 10.9 11.1 9.6 17.2 ≥95 1.8 10.1 3.6 13.1 9.2 Passive smoker (%) 32.7 37.5 30.6 40.5 20.2 0.11 Menstruation (%) 91.8 92.5 90.6 86.9 82 0.09 Parent death (%) 3.6 5 3.5 2.4 4.5 0.47 Parent divorce (%) 10 4.2 5.9 3.6 3.4 0.12 a One-way ANOVA and chi-squared analyses were used to test the trend of continuous and categorical variables, respectively, across the quintiles of DASH-style diet score Rostami et al. BMC Psychiatry (2019) 19:234 Page 4 of 7

Table 2 Food and nutrient intakes of adolescents according to quintiles of DASH-type diet Quintiles of DASH score (ranged from 0 to 40) Q1 (n = 98) Q2 (n = 97) Q3 (n = 97) Q4 (n = 98) Q5 (n = 98) P-trenda Components of DASH-diet style Fruits (serving/1000Kcal) 0.46 ± 35 0.54 ± 0.36 0.74 ± 0.56 0.79 ± 0.54 0.8 ± 0.42 < 0.001 Vegetables (serving/1000Kcal) 0.56 ± 0.29 0.73 ± 0.59 0.62 ± 0.3 0.83 ± 0.49 0.95 ± 0.5 < 0.001 Nuts, legume, seed (serving/1000Kcal) 0.33 ± 0.51 0.41 ± 0.45 0.51 ± 0.68 0.56 ± 0.43 0.61 ± 0.61 < 0.001 Low fat dairy (serving/1000Kcal) 0.22 ± 0.24 0.35 ± 0.29 0.39 ± 0.27 0.36 ± 0.22 0.45 ± 0.29 < 0.001 Whole grain (serving/1000Kcal) 1.97 ± 1.89 2.41 ± 2.3 2.85 ± 1.98 3.04 ± 2.21 3.5 ± 2.08 < 0.001 Red and processed meat (serving/1000Kcal) 0.31 ± 0.2 0.3 ± 0.3 0.27 ± 0.29 0.19 ± 0.15 0.14 ± 0.09 < 0.001 Sweetened beverage (serving/1000Kcal) 0.19 ± 0.19 0.13 ± 0.17 0.13 ± 0.22 0.12 ± 0.23 0.04 ± 0.06 < 0.001 Sodium (milligram/1000Kcal) 1.6 ± 1.2 1.19 ± 0.87 0.93 ± 0.75 1.08 ± 1.48 0.63 ± 0.71 < 0.001 Dietary nutrient intake Total energy (Kcal) 2567 ± 648 2505 ± 650 2616 ± 654 2791 ± 698 2687 ± 759 0.03 Protein (g/1000Kcal) 31.7 ± 5.9 33.4 ± 5.7 34.1 ± 5.4 33.9 ± 4.2 36.8 ± 5.4 < 0.001 Carbohydrate (g/1000Kcal) 132.4 ± 19.2 134.3 ± 18.8 136.3 ± 18.9 138.4 ± 16.4 142.02 ± 17.4 0.003 Total fat (g/1000Kcal) 40.05 ± 9.5 38.8 ± 8.7 38 ± 8.9 37.3 ± 7.2 34.7 ± 8.09 < 0.001 Dietary fiber (g/1000Kcal) 16.1 ± 6.2 15.9 ± 6.2 16.3 ± 7.07 16.8 ± 4.9 18.2 ± 5.3 0.04 Vitamin C (mg/1000Kcal) 28.1 ± 14 33.2 ± 16.2 37.6 ± 26.6 40.7 ± 25.06 42.1 ± 24.2 < 0.001 Vitamin D (mcg/1000Kcal) 0.76 ± 0.69 0.81 ± 0.66 0.85 ± 0.58 0.76 ± 0.44 1.07 ± 0.8 0.007 Folate (mcg/1000Kcal) 225 ± 51 225 ± 47 219 ± 49 230 ± 43 243 ± 50 0.01 Potassium (mg/1000Kcal) 1229 ± 237 1334 ± 282 1390 ± 265 1426 ± 259 1539 ± 250 < 0.001 Calcium (mg/1000Kcal) 379 ± 123 429 ± 144 441 ± 132 429 ± 112 479,139 < 0.001 Magnesium (mg/1000Kcal) 155.6 ± 36.6 225.1 ± 47.9 219.3 ± 49.9 230 ± 43.6 243.9 ± 50.5 < 0.001 Data reported as mean ± SD a Linear regression was used to test the trend of continuous variables according to quintiles lower intake of vegetables are associated with insomnia [5]. has been previously shown that individuals with low in- The Alpha-Tocopherol, Beta-Carotene Cancer Prevention takes of protein and carbohydrate reported symptoms of Study also showed that individuals with insomnia con- insomnia [23]. Tanaka et al., have shown that a low sumed fewer vegetables than subjects without insomnia protein and carbohydrate intake were associated with in- [21]. The findings from the Raising healthy Eating and Ac- somnia [24]. Moreover, a greater intake of protein and tive Living (REAL) Kids in Alberta indicate that individuals carbohydrate was associated with higher quality of sleep who consume higher intakes of fruits and vegetables expe- in Canadian grade 5 children [22]. It is possible that rienced better sleep quality [22]. sleep is influenced by availability of some amino acids In our study, individuals in the fifth quintile of adher- such as tryptophan. Serotonin is a sleep-inducing agent ence to DASH dietary pattern consumed more protein that was produced by tryptophan. Therefore, a low and carbohydrate than subjects in the first quintile. It protein diet may be related to symptoms of insomnia

Table 3 Multivariable-adjusted odds ratio of the associations between DASH-style diet and insomnia Quintiles of DASH score (ranged from 0 to 40) Q1 (n:98) Q2 (n:97) Q3 (n:97) Q4 (n:98) Q5 (n:98) P trenda Insomnia Crude 1.00 0.81 (0.45–1.44) 0.86 (0.46–1.62) 0.5 (0.25–1.01) 0.51 (0.26–1.00) 0.02 Model I 1.00 0.83 (0.46–1.48) 0.89 (0.47–1.69) 0.52 (0.26–1.04) 0.53 (0.27–1.07) 0.03 Model II 1.00 0.8 (0.44–1.43) 0.91 (0.48–1.73) 0.5 (0.25–1.01) 0.54 (0.27–1.08) 0.03 Model III 1.00 0.81 (0.45–1.45) 0.88 (0.46–1.68) 0.5 (0.25–1.02) 0.54 (0.27–1.09) 0.03 Model I: adjusted for age and menstruation; Model II: additionally, adjusted for physical activity and passive smoking; Model III: further adjustments for percentile of BMI a P for trend based on logistic regression by considering Median score in each quintiles of DASH-style diet Rostami et al. BMC Psychiatry (2019) 19:234 Page 5 of 7

because of a reduced availability of tryptophan [25]. On is associated with lower intake of sodium, sucrose, total the other hand, high protein diet increases serum con- fat, saturated and trans fat; while higher consumptions of centrations of catecholamines which are associated with protein, fiber, vitamins and minerals are seen in this more alertness [26]. Evidence from previous studies healthy pattern. In addition, recent evidences indicated expresses that higher blood glucose after carbohydrate DASH dietary pattern is a rich source of antioxidants and intake is related to early sleep onset and deep sleep [27]. improves glycemic responses [41]. In addition, after carbohydrate intake, brain serotonin Previous reports have hypothesized that sleep disturb- levels are increased possibly due to the facilitating effect ance might lead to the accumulation of free radicals in of carbohydrate on tryptophan transport [28]. the cerebral tissues that can increase cerebral oxidative We found that individuals with a high adherence to a stress [42]. It has previously showed that DASH- style DASH-style diet consumed lower amounts of sweetened diet can reduce an oxidative stress [43], which may also beverages and fat. These findings were confirmed by a support the importance of our findings, following DASH randomized-crossover study that showed a diet with low diet to prevent insomnia. fiber, high saturated fat and sugar is associated with Mental and metabolic disorders are important risk lighter and less restorative sleep [29]. It is known that a factors for sleep disturbances and as mentioned, ad- diet containing higher intakes of fat and sugar is associ- herence to DASH dietary pattern is associated with ated with risk factors of sleep problems including reduced incidence of these risk factors [11, 13]. obesity, metabolic diseases and psychological disorders Therefore, it seems that increasing adherence to the [30, 31]. Prior findings have also suggested that long- DASH- style diet may be one way to reducing sleep term consumption of sugar influenced negatively on disturbance. brain serotonin 5-hydroxytryptophan receptor sensitivity There is some major strength of our study. We [32]. In addition, one week following a high fat, low assessed dietary intake of study participants using a carbohydrate diet was associated with decreased sero- validated and reliable FFQ. Data collection was under- tonin release in the hypothalamus [33]. In our study, the taken with a high degree of quality control. To explore subjects with a greater adherence to a DASH- style diet the complex association of DASH dietary pattern with had a greater intake of potassium, magnesium, calcium, insomnia, we conducted multi-variate regression using vitamin D, vitamin C, folic acid and fiber. Our results several models. are consistent with previous studies that have indicated Although our study is the first to examine the associ- that intakes of vitamins, minerals and fibers are associ- ation between DASH- style diet and insomnia, some ated with better sleep quality [34, 35]. limitation should be considered to interpret findings our It has been previously reported that a sodium-restric- study. Causality cannot be proven using a cross-sectional tion may improve symptoms of obstructive sleep apnea study design. Moreover, students with insomnia may have compared with control group [36]. Moreover Kasai et al. altered their dietary habits. Our results might not be showed that a high sodium intake plays an important generalizable to other populations, given the relatively role in the pathogenesis of sleep apnea [37]. The mecha- small size of our sample, and this may influence the repre- nisms through which non-energy-yielding nutrients sentativeness of our findings. Using self-reported data may might influence on sleep health are unknown. It has result in recall bias and social desirability bias, and is been shown previously that adherence to a DASH diet further limitation of this study. might have beneficial effect on weight reduction in over- weight and obese adolescents [38]. It has also been shown that some of obese individuals suffer from Conclusions difficulty in maintaining sleep (DMS) and night eating We found an inverse, non-significant association be- syndrome (NES) [39, 40]. NES is a syndrome character- tween adherence to DASH- style diet and insomnia in ized by morning anorexia, evening hyperphagia, and in- adolescent girls. It is worth noting that sleep-related dis- somnia and it is most prominent during periods of life orders are associated with lower mental and physical stress [39]. Therefore, it seems that adherence to the abilities in children and adolescents and may increase DASH diet might play a substantial role in reduction of the risk of several chronic diseases in subsequent years. NES, although more studies will be needed in this It would appear to be important to pay attention to the regard. relationship between suitable lifestyle especially follow- We are unaware of other studies that have investigated ing a healthy dietary pattern such as DASH in children the relationship between some components of DASH and adolescents that may prevent the clinical manifesta- dietary pattern (meat, whole grain, nut, legume and tions of chronic diseases in the middle age. However, seeds) and sleep- related disorders. However, a greater ad- further studies particularly longitudinal studies are re- herence to a whole DASH- style diet, or its components, quired to confirm these findings. Rostami et al. BMC Psychiatry (2019) 19:234 Page 6 of 7

Abbreviations 6. Shi Z, McEvoy M, Luu J, Attia J. Dietary fat and sleep duration in Chinese BMI: Body mass index; DASH: Dietary approach to stop hypertension; men and women. Int J Obes. 2008;32(12):1835. FFQ: Food frequency questionnaire; ISI: Insomnia severity index; WC: Waist 7. Shilo L, Sabbah H, Hadari R, Kovatz S, Weinberg U, Dolev S, Dagan Y, circumference; WHR: Waist to hip ratio Shenkman L. The effects of coffee consumption on sleep and melatonin secretion. Sleep Med. 2002;3(3):271–3. Acknowledgments 8. Gianfredi V, Nucci D, Tonzani A, Amodeo R, Benvenuti AL, Villarini M, The authors would like to thank all students who participated in this study and Moretti M. Sleep disorder, Mediterranean diet and learning performance all school principals and sub-principals who welcomed us in their schools. among nursing students: inSOMNIA, a cross-sectional study. Ann Ig. 2018; 30(6):470–81. Authors’ contributions 9. Khayyatzadeh SS, Bagherniya M, Fazeli M, Khorasanchi Z, Bidokhti MS, HR and SSK formulated the research questions, designed the study and Ahmadinejad M, Khoshmohabbat S, Arabpour M, Afkhamizadeh M, Ferns wrote the first draft of manuscript. HT and MB collected the data and revised GA, et al. A Western dietary pattern is associated with elevated level of high the manuscript. SJM, SKF and MT determined the sample size, helped in sensitive C-reactive protein among adolescent girls. Eur J Clin Investig. 2018; designing the study, analyzing and interpretation of the data. GF revised the 48(4):e12897. manuscript and interpreted the results. MGM managed the whole project 10. Khayyatzadeh SS, Shafiee M, Far PE, Ziaee SS, Bagherniya M, Ebrahimi S, and contributed in all steps. All authors reviewed the manuscript. All authors Boromand N, Ferns GA, Ghayour-Mobarhan M. Adherence to a healthy read and approved the final manuscript. dietary pattern is associated with less severe depressive symptoms among adolescent girls. Psychiatry Res. 2019;272:467–73. 11. Khayyatzadeh SS, Mehramiz M, Mirmousavi SJ, Mazidi M, Ziaee A, Kazemi- Funding Bajestani SMR, Ferns GA, Moharreri F, Ghayour-Mobarhan M. Adherence to a This study was financially supported by Mashhad University of Medical Dash-style diet in relation to depression and aggression in adolescent girls. Sciences, Mashhad, grant number, 931188. Psychiatry Res. 2018;259:104–9. 12. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek Availability of data and materials E, Conlin PR, Miller ER, Simons-Morton DG. Effects on blood pressure of The datasets used and analyzed during the current study are available from reduced dietary sodium and the dietary approaches to stop hypertension the corresponding author on reasonable request. (DASH) diet. N Engl J Med. 2001;344(1):3–10. 13. 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